Joint statement from UK organisations

The media are reporting that governments across the world are developing ethical guidelines and decision tools to help their doctors to prioritise patients for hospital admission and treatment (1). This difficult work is designed to ensure that the incredibly tough decisions about who gets what treatment at this time of crisis are made as fairly and effectively as possible by their doctors, who if these guidelines and decision tools are needed will be working in very stressful and challenging situations.

As organisations and individuals dedicated to supporting older people and protecting their rights we are joining together to say that if and when our own governments across the UK do similar work it is vital that they all continue to uphold fundamental human rights principles.  

Any suggestion that treatment decisions can be blanket ones, based on age alone or with a person’s age given undue weight as against other factors, such as their usual state of health and capacity to benefit from treatment, would be completely unacceptable. For many years we have known that chronological age is a very poor proxy for an individual’s health status and resilience – something we all see among the older people in our lives. To ignore this and to revert to an approach based solely or mainly on age would be, by definition, ageist, discriminatory and morally wrong.

We strongly believe that decisions about treatment should always be made on a case by case basis through honest discussion between doctors, patients and their families that factor in the risks, benefits, and people’s wishes. There is no reason to abandon this long-established good practice now; in fact the current health emergency makes it more critical than ever that we keep it. 

In addition, the fact that someone is in need of care and support, in a care home or their own home, should not be used as a proxy for their health status, nor blanket policies applied – for example, over whether they should be admitted to hospital. To make such decisions without considering either an older person’s needs or their capacity to benefit from hospital treatment would be discriminatory and unfair.” 

(1) See for example, https://www.dailymail.co.uk/news/article-8162357/US-coronavirus-New-York-hospitals-guidance-use-LOTTERIES-ventilators-shortage.html  ; https://www.nytimes.com/2020/03/12/world/europe/12italy-coronavirus-health-care.html  

Caroline Abrahams, Charity Director Age UK

Deborah Alsina, Chief Executive Independent Age

Jane Ashcroft, Chief Executive Anchor Hanover

Helena Herklots, Commissioner for Older People in Wales

Victoria Lloyd, Chief Executive Age Cymru

Eddie Lynch, Commissioner for Older People in Northern Ireland

Dr Donald Macaskill, Chief Executive Scottish Care

Linda Robinson, Chief Executive Age Northern Ireland

Brian Sloan, Chief Executive Age Scotland

Age shall not limit them…

In life you sometimes have weeks at the end of which you look back and feel as if you are witnessing someone else’s story – this week has felt a bit like that for me.

It has been a very busy week responding to the Coronavirus outbreak from a social care perspective. Part of it has led me to being involved in national conversations with colleagues in the acute and palliative care communities across Scotland. I have to admit that I have found some of the conversations very hard – painting as they did a picture of the raw reality of impossibly hard clinical decisions which may have to be made in the coming weeks and months. Alongside this I have read papers which have described the criteria which may potentially have to be utilised in a context of limited resources.

As many of you know over the years I have written and spoken about human rights, about ageism and age discrimination, and have sought to challenge the casual assumptions which serve to dismiss and limit the contribution, value and role of older citizens in modern society. In ordinary times it is perhaps easy to gain an audience for such conversations as few would intellectually defend a position which values another solely by their chronological age. But we are not living in ordinary times, so I want to in this piece reflect on what are the risks of discrimination and impact upon the human rights of older people in the face of this pandemic.

Hard decisions

One thing is a self-evident risk and some have suggested almost inevitable and that is that no matter how many respirators we manage to get access to, no matter how many ITU beds and critical care beds we manage to put into commission, there will not be sufficient resources including pharmacological ones to enable every single person who reacts severely to Covid-19 to get the optimal clinical response which they might expect in ordinary times.

Phrases to describe this resource restriction such as ‘capacity challenge,’ ‘the management of patients’ and ‘clinical prioritisation’ have now come out from clinical contexts into ordinary parlance. What is meant in effect is ‘rationing’ and the establishment of criteria to determine who gets what treatment and support. Before I go on much further I want to assert that I know of no clinician, carer or nurse who will not seek to do their absolute best for those they are caring for. I know of no politician or strategist who is not today doing their best to ensure we maximise the resources we can get hold of. Our staff in social care and the NHS are dedicated to the alleviation of pain and distress and will always seek to put the person at the heart of their practice and care. I know that the decisions they may have to make and take will be emotionally and psychologically traumatic for these professionals.

Having said that we need now, I believe, as a wider society, to be both more aware of and to give assent to the criteria for such decision making, both to support the staff making those decisions and to protect the lives of some of our most vulnerable citizens and their families.

 Covid-19 and older people

Anyone can catch Covid-19 as we have witnessed in the last few days in the United Kingdom with sad news of fatalities across the age spectrum.

But what is also clear is that the virus does not treat everyone equally. We know from the mortality figures from across the world that older individuals, people with a supressed immune system and multiple co-morbidities are particularly likely to be chronically affected and to perhaps die.

The impact on older people is hardly surprising. As you get older your immune system is weaker, lungs are less responsive and there is a greater likelihood of you having multiple conditions such as dementia, heart disease, cancers and other conditions which make recovery from any illness slower and harder.

It is because of this that on Wednesday the World Health Organisation Director General Tedros Adhanom Ghebreyesus said:

“We need to work together to protect older people from the virus …They are valued and valuable members of our families and communities… Older people carry the collective wisdom of our societies. Ensure their needs are being met for food, fuel, prescription medication, and human interaction.”

But age is not a predicator of weakness. There are plenty individuals in older life who are physically more responsive than those half their age. It is not age per se that means someone is likely to respond poorly to Covid-19 but underlying conditions, co-morbidities and frailty.

Yet in some parts of the world one of the concerning issues has been the extent to which age has been automatically assumed to be a dispositive or exclusive indicator of mortality risk from Covid-19. These models ignore the other realities which include that one’s gender and pre-existing conditions are key factors that correlate to the probability of dying from Covid-19. Yet we are not saying that treatment should only be given to women.

This mistaken assumption around age is both clinically wrong, ethically dangerous and potentially lethal.

How do you prioritise?

We are clearly not the first country to potentially be facing such decisions around resource prioritisation. Italy and Spain are ahead of us in the pandemic and there we have witnessed a whole range of responses to the necessity of prioritising resources.

Faced with the risk of constrained resources in a pandemic emergency we have to establish at the outset and before such realities arise very clear criteria on which clinicians are enabled to make judgements, often in pressurised circumstances and frequently with only partial clinical histories about patients and individuals. We have to prioritise. This process of ‘triage’ is well known. It enables those with the greatest clinical need to have those met as a priority. Anyone who has been to an Accident and Emergency Department will know this all too well.

What matters is the basis on which you establish the triage or resource allocation or rationing system. From an ethical and human rights perspective those criteria have to be as neutral and universally accepted as possible. They cannot be based on discriminatory characteristics or presumptions. In the current pandemic I would argue that it must surely be clinical factors alone which are used to determine who has the greatest need and who is likely to have the best clinical outcome. Age undeniably influences this process, but it can never be the sole criteria or even an overarching criteria. It may be the easiest one to utilise because we can determine age very quickly compared to the other influencers such as the clinical benefit of treatment, the frailty of the person and the extent to which they have co-morbidities.

To base any treatment principle on an ethical model which considers chronological age as the ‘key’ significant indicator is quite simply to engage in the most obscene discrimination and to effectively devalue any human life beyond a certain age.

Human rights

The horrors and the barbarity of the Nazi regime resulted in the desolation of Europe in the 1940s and in the deaths of millions. Out of that agonised ground grew the international set of rights which are the barometer by which we have come to determine what it truly means to be human. These human rights are a bulwark not just against extremism, but they are the standard bearer for action and a guide for response especially in times of challenge and emergency. Any ethical or clinical framework has to be able to stand up to the rigour of a human rights analysis. I am not at all convinced that any framework which advances age as its significant criterion can be defended in human rights terms either legally or morally. How can such be defensible against the articulation of the right to life or of the prohibition not to engage in inhumane or degrading treatment? How can such be evidence of a State and Government fulfilling its duty to do all things in a manner which is compatible with the UN Declaration of Human Rights?

We can do better…

Flexibility and compromise, responsiveness and speed will unsurprisingly be the watchwords of the next days and weeks, but dignity, humanity, equality and human rights must also be the language behind our ethical choices. A sharply utilitarian view of the world ignores the advances in our understanding of geriatric medicine and downplays the capacity and contribution of millions of our fellow citizens.

As I have commented before the way in which we respond to coronavirus will determine the society we will be for years to come. Will we be one which values all regardless of age? Will we make really hard decisions based on individual clinical prognosis or will we take the delusory easier but exceptionally dangerous road of determining that age is the main or significant determinant when we have to choose not to treat?

Older people vulnerable to Covid-19 in Scotland and across the United Kingdom today are grandparents and parents. They are workers, caregivers and volunteers. They are not disposable. They are the best of us, and we have a duty to be the best for them.

Dr Donald Macaskill

CEO, Scottish Care

Scottish Care, today launches the Tech Device Network – an initiative to help connect individuals supported by Scotland’s care services with their loved ones.

With social distancing measures in place and visits to care homes being suspended to protect staff and the elderly, we need to be looking at smart ways to bridge the gap and bring people together.

The idea was started when publicist Jenn Nimmo-Smith, Director of Electric Shores, was concerned about her mum during the coronavirus lockdown. She was able to video call with her mum on an iPad but was aware that not all residents would be able to have face-to-face communication. While social care workers are doing what they can to maintain connections, this initial approach has led to today’s appeal to help ensure that more families and loved ones can stay in contact.

We are looking for

Any device which can be used to enable social connection e.g. through apps and internet connection. This includes tablets, laptops, smart TVs and larger models of smartphones.

Device condition

For security and safety reasons, devices should ideally be in new/unused condition or have been minimally used. Devices should be donated with any required accompaniments e.g. chargers or remotes.

Protecting privacy

To protect people’s privacy, donated devices should be cleared of any personal information/data and protected against malware.

Can I lend rather than donate?

Ideally, we’d be looking for devices to be donated to services at this time. However, we may be able to help with the loaning of devices in certain circumstances – please get in touch with us to discuss this.

Is it safe to donate?

We ask all donors to follow current infection control and hygiene guidance to ensure that donated devices are, as far as possible, clean and safe. We will also liaise with donors and recipients around the safest way to collect or deliver devices.

How will my donation be used?

Any donated device should be used for the sole purpose of improving the wellbeing of individuals receiving support. We will be asking people to use the hashtag #TechConnectsCare on social media to share the ways in which devices are making a difference to their service!

Social care workers are at the front line of protecting the most vulnerable age group right now as health and care services unite to fight coronavirus. They will play a critical role in relieving pressure on hospitals over the weeks ahead. Residents of care homes and people supported in their own homes may feel anxious and the ability to see a familiar face and talk to their loved ones will help alleviate some of the anxiety they will be feeling.

Jenn Nimmo-Smith, said:  “I’m super happy to have partnered with Scottish Care to launch this Tech Device Network. As my Mum is in a care home, now more than ever video calling is going to be our lifeline to connect. My hope is that this will help other families and those with loved ones who they can’t visit given the current Covid-19 pandemic to stay in contact and enable that connection that is so important and vital to our relationships. I’d also like to send my love to all the people going through this just now, you’re not alone and we can get through this together.”

Becca Young, Policy & Research Manager at Scottish Care, said: “The current Covid-19 pandemic is impacting all of our lives in unprecedented ways and making us think differently about how we remain connected to each other whilst physically distanced. We are delighted to partner with Jenn to launch this Tech Device Network, supporting the wellbeing of our older and vulnerable citizens receiving care here in Scotland through access to technology. Many are likely to be experiencing significantly reduced physical contact and social engagement as a result of the current pandemic and this initiative is a positive way in which we can keep our communities connected.”

If you can help keep families connected during this crisis, join our appeal today.

For more info and to donate a device please go to: https://scottishcare.org/techdevicenetwork

Today (21 February) Scottish Care has issued on open letter to Jackson Carlaw MSP, Leader of the Scottish Conservative & Unionist Party,  from Scottish Care CEO, Dr Donald Macaskill.   It has also been issued to all other Scottish Party leaders.

The letter expresses Scottish Care’s profound concerns regarding the impact of the new immigration system on social care in Scotland. It calls for social care to be made an area of priority in order to ensure that we can continue to recruit social care workers from outwith Scotland.

You can read the open letter here.

For further information or to request an interview with Dr Macaskill, please email [email protected]